scholarly journals Development and Validation of a Simplified Probability Assessment Score Integrated With Age‐Adjusted d ‐Dimer for Diagnosis of Acute Aortic Syndromes

2021 ◽  
Vol 10 (3) ◽  
Author(s):  
Fulvio Morello ◽  
Paolo Bima ◽  
Emanuele Pivetta ◽  
Marco Santoro ◽  
Elisabetta Catini ◽  
...  
Keyword(s):  
Aortic Dissection ◽  
Assessment Tool ◽  
Probability Assessment ◽  
Derivation Cohort ◽  
Net Reclassification Improvement ◽  
Clinical Probability ◽  
Acute Aortic Syndromes ◽  
Care Guidelines ◽  
Increased Sensitivity ◽  
Detection Score

Background When acute aortic syndromes (AASs) are suspected, pretest clinical probability assessment and d ‐dimer (DD) testing are diagnostic options allowing standardized care. Guidelines suggest use of a 12‐item/3‐category score (aortic dissection detection) and a DD cutoff of 500 ng/mL. However, a simplified assessment tool and a more specific DD cutoff could be advantageous. Methods and Results In a prospective derivation cohort (n=1848), 6 items identified by logistic regression (thoracic aortic aneurysm, severe pain, sudden pain, pulse deficit, neurologic deficit, hypotension), composed a simplified score (AORTAs) assigning 2 points to hypotension and 1 to the other items. AORTAs≤1 and ≥2 defined low and high clinical probability, respectively. Age‐adjusted DD was calculated as years/age × 10 ng/mL (minimum 500). The AORTAs score and AORTAs≤1/age‐adjusted DD rule were validated in 2 patient cohorts: a high‐prevalence retrospective cohort (n=1035; 22% AASs) and a low‐prevalence prospective cohort (n=447; 11% AASs) subjected to 30‐day follow‐up. The AUC of the AORTAs score was 0.729 versus 0.697 of the aortic dissection detection score ( P =0.005). AORTAs score assessment reclassified 16.6% to 25.1% of patients, with significant net reclassification improvement of 10.3% to 32.7% for AASs and −8.6 to −17% for alternative diagnoses. In both cohorts, AORTAs≥2 had superior sensitivity and slightly lower specificity than aortic dissection detection ≥2. In the prospective validation cohort, AORTAs≤1/age‐adjusted DD had a sensitivity of 100%, a specificity of 48.6%, and an efficiency of 43.3%. Conclusions AORTAs is a simplified score with increased sensitivity, improved AAS classification, and minor trade‐off in specificity, amenable to integration with age‐adjusted DD for diagnostic rule‐out.

Abstract P73: Comparison of Hospital-Acquired Anemia and TIMI Bleeding for Mortality Prediction in Patients with Acute Myocardial Infarction

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Adam C Salisbury ◽  
Amit P Amin ◽  
Karen P Alexander ◽  
Frederick A Masoudi ◽  
Yan Li ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
At Risk ◽  
Assessment Tool ◽  
Mortality Prediction ◽  
Logistic Regression Models ◽  
Net Reclassification Improvement ◽  
Risk Patients ◽  
Poor Outcomes ◽  
Hospital Acquired

Background: In-hospital bleeding and new onset, hospital acquired anemia (HAA) are both associated with higher mortality in acute myocardial infarction (AMI). Since bleeding is variably defined and often poorly documented, HAA could be a better method to identify at-risk patients, if its prognostic ability were at least as good as documented bleeding. We directly compared the association of HAA and TIMI bleeding with 1-year mortality. Methods: Among 2,803 AMI patients who were not anemic at admission in the 24-center TRIUMPH registry, the presence and severity of HAA and TIMI bleeding were prospectively collected to identify their relative discrimination of 1-year mortality. Logistic regression models, accounting for clustering using generalized estimating equations, were fit for 1) no bleeding, TIMI minimal, minor and major bleeding and 2) no HAA, mild (hemoglobin (Hgb) > 11 g/dl), moderate (Hgb 9 - 11 g/dl) and severe HAA (Hgb < 9 g/dl). Discrimination was compared using c-statistics and reclassification was assessed using the integrated discrimination improvement (IDI), which measures a model's improvement in average sensitivity without sacrificing average specificity vs. another model, and the continuous net reclassification improvement (NRI), to identify the proportion of patients correctly reclassified by the HAA model. Results: HAA was more common (mild: 33%, moderate: 10%, severe 2%) than TIMI bleeding (minimal: 5%, minor: 3%, major 1%). Over 1-year follow-up, 111 patients (4%) died. The HAA model was superior to TIMI bleeding model for 1-year mortality prediction (c-statistic 0.60 vs. 0.51, p<0.001). The IDI of the HAA vs. the bleeding model was 0.009 (95% CI 0.005 - 0.014) and the relative IDI was 0.26 (26% better average discrimination), with a NRI of 0.32 (0.13-0.50) - 17% of patients with events were correctly reclassified to a higher risk while 14% of patients without events were correctly reclassified to a lower risk by the HAA model. Conclusions: HAA is better than TIMI bleeding for identifying 1-year mortality after AMI hospitalization, and may better identify patients without recognized bleeding who are also at risk for poor outcomes. HAA may be useful to identify high-risk patients and as a quality assessment tool.

Diseases of the Aorta

2018 ◽  
Author(s):  
Anna M Booher ◽  
Kim A Eagle
Keyword(s):  
Aortic Dissection ◽  
Thoracic Aortic Aneurysm ◽  
Clinical Presentation ◽  
Abdominal Aortic Aneurysms ◽  
Aortic Aneurysms ◽  
Type B ◽  
Thoracic Aortic Aneurysms ◽  
Computed Tomographic ◽  
Abdominal Aortic ◽  
Acute Aortic Syndromes

This review covers the major presentations affecting the aorta: aortic aneurysms (abdominal aortic aneurysms and thoracic aortic aneurysms), acute aortic syndromes (including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer), other nonacute aortic processes, and traumatic disease of the aorta. The section on abdominal aortic aneurysms covers screening, clinical presentation, diagnostic evaluation, management to reduce the risk of aneurysm rupture, open surgical treatment and endovascular aortic repair, and the role of medical therapy. The section on thoracic aortic aneurysms also covers pathophysiology, etiology, and inherited and inflammatory conditions. Aortic dissections affect either the ascending aorta (type A) or the descending aorta (type B) and may be classified as acute or chronic. The discussion of aortic dissection describes the clinical presentation, diagnostic steps and decisions, and treatment for both type A and type B dissections. The figures include two algorithms: a potential management strategy for patients with thoracic aortic aneurysm and a logical procedure for the evaluation and treatment of a suspected aortic dissection. Figures also include illustrations, computed tomographic images, and echocardiograms of various aortic presentations. Tables list normal aortic dimensions by computed tomographic angiography and echocardiography, etiology and associated factors in diseases of the aorta, revised Ghent criteria for the diagnosis of Marfan syndrome, size criteria for elective surgical intervention in thoracic aortic aneurysm, and independent predictors of in-hospital death. Also included is a follow-up imaging timeline for acute aortic syndromes. This review contains 9 figures, 6 tables, and 132 references.

Is Clinical Probability Assessment of Deep Vein Thrombosis by a Score Really Standardized?

2000 ◽  
Vol 83 (05) ◽  
pp. 788-789 ◽  
Author(s):  
Alessandro Bigaroni ◽  
Arnaud Perrier ◽  
Henri Bounameaux
Keyword(s):  
Deep Vein Thrombosis ◽  
Probability Assessment ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Deep Vein

Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes

2019 ◽  
Vol 40 (24) ◽  
pp. 1952-1960 ◽  
Author(s):  
Peiman Nazerian ◽  
Christian Mueller ◽  
Simone Vanni ◽  
Alexandre de Matos Soeiro ◽  
Bernd A Leidel ◽  
...  
Keyword(s):  
Sensitivity And Specificity ◽  
Failure Rate ◽  
Diagnostic Algorithm ◽  
Cardiac Ultrasound ◽  
Advanced Imaging ◽  
Focused Cardiac Ultrasound ◽  
Clinical Probability ◽  
Acute Aortic Syndromes ◽  
European Society Of Cardiology ◽  
Rule Out

Abstract Aims The diagnosis of acute aortic syndromes (AASs) is challenging and requires integrated strategies. Transthoracic focused cardiac ultrasound (FoCUS) is endorsed by guidelines as a first-line/triage tool allowing rapid bedside assessment of the aorta. However, the performance of FoCUS in the European Society of Cardiology-recommended workup of AASs awaits validation. Methods and results This was a prespecified subanalysis of the ADvISED multicentre prospective study. Patients with suspected AAS underwent FoCUS for detection of direct/indirect signs of AAS. Clinical probability assessment was performed with the aortic dissection detection risk score (ADD-RS). Case adjudication was based on advanced imaging, surgery, autopsy, or 14-day follow-up. An AAS was diagnosed in 146 (17.4%) of 839 patients. Presence of direct FoCUS signs had a sensitivity and specificity of 45.2% [95% confidence interval (CI) 37–53.6%] and 97.4% (95% CI 95.9–98.4%), while presence of any FoCUS sign had a sensitivity and specificity of 89% (95% CI 82.8–93.6%) and 74.5% (95% CI 71–77.7%) for AAS. The additive value of FoCUS was most evident within low clinical probability (ADD-RS ≤1). Herein, direct FoCUS signs were identified in 40 (4.8%) patients (P < 0.001), including 29 with AAS. ADD-RS ≤1 plus negative FoCUS for AAS rule-out had a sensitivity of 93.8% (95% CI 88.6–97.1%) and a failure rate of 1.9% (95% CI 0.9–3.6%). Addition of negative D-dimer led to a failure rate of 0% (95% CI 0–1.2%). Conclusion FoCUS has additive value in the workup of AASs. Direct FoCUS signs can rapidly identify patients requiring advanced imaging despite low clinical probability. In integrated bundles, negative FoCUS is useful for rule-out of AASs.

Acute aortic syndromes

2016 ◽  
Author(s):  
Demosthenes G. Katritsis ◽  
Bernard J. Gersh ◽  
A. John Camm
Keyword(s):  
Aortic Dissection ◽  
Intramural Haematoma ◽  
Penetrating Atherosclerotic Ulcer ◽  
Diagnosis And Management ◽  
Acute Aortic Syndromes

Acute aortic syndromes comprise aortic dissection, intramural haematoma, and penetrating atherosclerotic ulcer. Classification, presentation, diagnosis, and management of these conditions are discussed.

Don't get in a flap!: A case report of progression through the spectrum of an acute aortic syndrome

Vascular ◽  
2014 ◽  
Vol 22 (6) ◽  
pp. 454-457 ◽  
Author(s):  
Andrew MTL Choong ◽  
Saroj Das ◽  
Nicholas Mulrenan ◽  
Mohamad Hamady ◽  
Protip Bose
Keyword(s):  
Case Report ◽  
Chest Pain ◽  
Aortic Dissection ◽  
Vascular Surgery ◽  
Acute Type ◽  
Medical Team ◽  
Acute Aortic Syndrome ◽  
Type B ◽  
Type B Aortic Dissection ◽  
Acute Aortic Syndromes

Purpose To present a single case that clearly demonstrates the progression through the whole spectrum of an acute aortic syndrome, from a solitary penetrating aortic ulcer (PAU) through to multiple PAUs with intra-mural haematoma (IMH) progression. The index images show that despite the clinical presentation of an acute type B aortic dissection, a classical dissection flap is never demonstrated in this patient and thus highlights the need for early input from vascular surgery for all potential acute aortic syndromes. Case report We present the case of a 71-year-old lady who attended the emergency department with hypertension and inter-scapular chest pain. Upon investigation with computed tomography aortography (CTA), she was found to have a solitary PAU only with minimal IMH. She did not demonstrate any classical radiological signs of acute type B aortic dissection. She was admitted under a medical team and her chest pain abated with no treatment. The treating medical team adjusted her anti-hypertensive medication and discharged her home with an urgent vascular surgical outpatient appointment for further follow-up and surveillance. We acknowledge that a preferred approach would have been, at least admission and close blood pressure monitoring, with a repeat CTA the next day. Two days later, she represented with further chest pain and on repeat CTA was found to have multiple PAUs and progression of the small IMH. She was then admitted under vascular surgery and subsequently transferred to the parent tertiary referral vascular surgical unit. Despite aggressive anti-hypertensive management, she had persistent intractable chest pain and was treated with a single thoracic stent graft. Completion angiography demonstrated total resolution of the PAUs. Conclusion This case along with index images demonstrates the whole spectrum of the acute aortic syndrome from a solitary PAU to multiple PAUs with IMH extension. Despite an eventual clinical picture of an acute type B aortic dissection, there was a notable absence of a classical dissection flap on any imaging. We recommend that all aortic pathologies should be at least discussed with and preferably managed by vascular surgeons. The absence of a classical dissection flap on imaging is not a contra-indication to emergent treatment with thoracic stent grafting and in select patients is actually the only therapy that will treat this pathology.

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